“This collaborative is important, not just to this Health Board, but to me personally as I have had too many final conversations with patients and looked into the eyes of too many children who I knew would not survive because of sepsis”. With these inspirational words Paul Buss, Paediatrician and Medical Director of Aneurin Bevan University Health Board (ABUHB) launched the organisation’s sepsis collaborative programme for 2015.
This event marked the starting point for the Health Board of what will be a year of intense activity with the single aim of reducing the number of deaths due to sepsis. The plan is to start making improvements with small clinical teams in two emergency departments and two ward areas and then to roll out learning and success from these to the rest of the organisation over a series of 90 day periods. They will be closely supported in doing this by a team from 1000 Lives Improvement including David Williams and myself.
Although ABUHB have achieved a lot as part of the All Wales Rapid Response to Acute Illness Learning Set (RRAILS) in terms of standardising processes and improving recognition of acute deterioration using NEWS, they, in common with all other Welsh Hospitals, have so far failed to demonstrate a reduction in mortality due to sepsis specifically.
In order to learn how to we might achieve this goal four colleagues and I were fortunate enough to visit Dartmouth-Hitchcock Healthcare as part of a study tour. Dartmouth-Hitchcock is a healthcare system in New Hampshire which serves a population of almost two million. In an astonishing period of just seven months in 2013, building upon the learning from the High Value Healthcare Collaborative (HVHC) of which they are a member they demonstrated, amongst other successes, a reduction in sepsis related deaths in the Emergency Department from a rate of approximately 50% to zero.
In my opinion the single biggest factor influencing the achievement of this was the decision made by CEO Jim Weinstein that ‘this unacceptably high death rate from sepsis in this organisation will stop”. The positive actions and results that followed at considerable pace all flowed from this initial well publicised and non-negotiable decision at the head of the organisation.
This is why I was so impressed to hear Paul demonstrate his personal commitment at this organisational meeting but to also see the attendance of Denise Llewellyn, Director of Nursing and many senior ABUHB figures. It was also noticeable that even at a time of unprecedented Winter pressures the attendance from the Emergency departments was considerable demonstrating the commitment to reduce sepsis mortality from ‘Ward to Board’.
The overriding message expressed was not so much permission but an expectation that all staff should act to recognise, escalate and rapidly treat sepsis. This expectation is neatly encapsulated in the strapline that the collaborative is adopting from the UK Sepsis Trust “Sepsis – spot it, treat it, together we can beat it”.
At ‘an introduction to healthcare apps’ yesterday, based in Swansea University but shared via the wonders of the National Virtual Incubator between dozens of people in various ‘nodes’ across the UK.
Several software and app developers spoke about their experience working with or within the NHS, how glacial the speed of progress could be but also how effective a ‘quality mark’ the NHS was internationally.
Ewan Davis spoke about the importance off cross platform and form factor agility but it was reiterated by every speaker that in order to be successful app design must be shaped and influenced by the clinicians and patients for whom it is intended. Bruce Hellman described the profound impact upon his company’s design of employing a medic with experience in clinical trials.
However, technology has always had an equally dramatic effect upon how medicine is practiced. The application of X ray imaging forever changed the direction of healthcare as have each subsequent innovation in imaging. Telemetry has allowed patients to be monitored and diagnosed remotely, point of care testing has profoundly altered how and where chronic conditions are managed, whilst the portable automated defibrillator has given the entire population the potential to save lives.
When Wales implemented the National Early Warning Score (NEWS) in all hospitals we launched the NEWS_Wales app mainly as a publicity tool but also to draw attention to the need to be aware of the likelihood of sepsis.
The app has been downloaded over 2000 times and, although we had secondary care in mind when it was designed, I have had anecdotal reports of Paramedics and GPs using it to confirm the need to pre alert and provide a language for communication with acute hospital teams.
Although this is a minor example, I do wonder about the potential of this nascent technology to shape the way that we practice medicine and nursing. It is probably overstating the case to claim that ‘Who controls the healthcare application controls the application of healthcare’ but it is essential that clinicians play a leading role in development and design of this amazing technology.
One of the themes that emerged from the Capita Conference on sepsis that I was lucky enough to speak at yesterday, was that of using the tools that are already available now rather than postponing action on sepsis until we have the ideal screening tool and system for implementation.
Jeff Keep, a consultant in Emergency Care, used the analogy with Stroke care and gave us his estimate of the number of false FAST positives as being 50%. So of the people admitted to his ED who had been identified by paramedics as having a stroke , about half actually did not. However the care and outcomes for those people who had had strokes was improved whilst there was not a detrimental effect for those who had not.
In Wales, a positive sepsis screen is defined as NEWS score 3 or more PLUS 2 or more SIRS criteria PLUS suspicion of new infection whilst in Scotland the definition differs only in that the NEWS score is 4 or more.
It is probable that there will be some false positives from sepsis screening using these criteria although the work on the Outcomes Database at Nevill hall Hospital suggests not many. Of extreme importance though is that for patients with sepsis the use of the screening tool will be literally life saving whilst the consequences for those few patient who are incorrectly screened are likely not to be serious.
The strength of standardised screening and treatment tools for sepsis lies both in the necessity to ‘opt out rather than opt in’ to delivering the sepsis six within one hour and, as Mark Radford reminded us, the permission that it gives to all members of staff to insist that action takes place immediately.
As with adoption of the NEWS score in Wales I have always been of the opinion that it is better to standardise the use of a ‘good enough’ tool now than it is to wait for perfection to arrive.